1. Viral Hepatitis Integration in an STD Clinic Do Injecting Drug Users Benefit?
National Hepatitis Coordinators’ Conference January 26 – 30, 2003
Robin R. Hennessy
Karen Schlanger, MPH
Isaac Weisfuse, MD, MPH
New York City Department of Health and Mental Hygiene

2. Overview Viral Hepatitis Integration Project (VHIP) in NYC
Research Questions
Methods
Results
Conclusions, Discussions and Recommendations

3. VHIP Project Description
Integrate viral hepatitis services in an STD/HIV clinic setting
Evaluate the impact of integration
Viral Hepatitis Services:
Hepatitis A Vaccine
Hepatitis B Vaccine (limited screening)
Hepatitis C Counseling, Testing and Referral

4. VHIP Clinic Background
Riverside STD Clinic, Upper Manhattan
Race/Ethnicity
34% Hispanic
31% Black
25% White
10% Other
VHIP project coordinator on site

5. Clinic and VHIP Census May 2000 – October 2002
30 Months
Nearly 30,000 visits
not unique patients
6,436 patients received a hepatitis service
~ 1/3 of clinic population
Actual patient visits 29,744
Be sure to emphasize that this number is not UNIQUE individuals but number of visits
6436 are unique individuals who have been served by the VHIP

6. Vaccine Delivery May 2000 – October 2002
Hepatitis A
1,968 doses administered (1,498 1st doses)
34% returned for second dose
Hepatitis B
8,566 doses administered (4,683 1st doses)
55% returned for second dose
30% completed series
VHIP Return rates are comparable and perhaps slightly better than in similar venues and urban areas

7. Screening Services May 2000 – October 2002
Hepatitis B
4,479 patients screened
2% (84) chronic carriers
17% (759) immune (resolved past infection)
Hepatitis C
2,249 patients screened
8% (179) antibody+ (RIBA confirmed)
Prior to August of this year, all patients receiving b vaccine were also screened for surface antigen and core antibody
However, our overall percentage of exposure is 19% and the CDC recommendation for pre-vaccination screening is a baseline prevalence of 30%, we no longer offering routing screening but selected screening to IDU, MSM, HIV+, liver disease
1999 blinded sero survey 2% hcv prevalence

8. Background Reason for asking research question: Hepatitis C testing
6.6% (76/1,146) reported IDU history during pre-test
HIV testing
0.5% (20/3,738) reported IDU history during pre-test
What’s going on?

9. Research Questions
Does the VHIP bring new clients to the STD clinic – specifically injection drug users (IDU)?
Do these “new” clients utilize traditional STD/HIV services?

10. Methods Data Collection
VHIP Database
Hepatitis Services (vaccine, screening)
Risk Assessments
Medical Record Review
Reason for visit (symptoms, referral, etc.)
Have an STD exam
IDU risk assessment
STD/HIV (tests, results, diagnosis)
HIV CTS Database

11. Methods Data Sources Data VHIP Database set used for this analysis
If IDU history=Yes
STD Medical Record Review
If HIV test=Yes
If a patient reported a history of injection drug use during vaccine visit or HCV pre-test visit, the medical chart was reviewed if HIV test was indicated on medical chart, a link was created to the HIV CTS dataset
HIV Counseling and Testing (HIV CTS) Database

12. Methods Case Definitions
Hepatitis services specifically if:
Received vaccine only
Referral from drug treatment center for hepatitis C testing was recorded
STD services specifically if:
Complained of symptoms
Reason Unknown if:
Above criteria not met
This will become clear later

13. Study Population May 2000 – October 2002
202/6,436 (3%) patients receiving hepatitis services reported a history of IDU
20% (40/202) of these patients reported current use
Information was collected for ALL 202 IDU patients through either
Found 97% of charts!
chart review (195) or
laboratory/HIV log book (7)

14. Hepatitis Vaccine (N=202)
31% (62) received hepatitis A vaccine
78% (148) received hepatitis B vaccine
Hepatitis is a large health burden for this population
19% hep b exposure overall
8% hep c overall

15. Hepatitis Screening (N=202)
149 (74%) tested for hepatitis B
46% (69/149) with evidence of past exposure
Clinic wide: 15% past exposure
150 (74%) tested for hepatitis C
60% (90/150) tested positive (RIBA+)
Clinic wide: 8%
1999 Seroprevalence Study: 2%
Hepatitis is a large health burden for this population
19% hep b exposure overall
8% hep c overall

16. STD Services (N=202) 149 (78%) were interviewed by a physician
53% (79/149) of these patients denied IDU history when asked by a physician
106 (53%) had an STD exam
43% (46/106) diagnosed with an STD
97 (48%) were tested for HIV
4% (4/97) tested positive

17. Results Reason for Visit (N=202)
78 (39%) of IDU are known to have visited the STD clinic specifically for hepatitis services
49 vaccine only
29 referred from DTC for HCV testing
92 (45%) Reason Unknown
32 (16%) Symptomatic for an STD
This is the money shot – hepatitis brought them into the clinic!
Remember we talked earlier about reason for visit

18. Results Reason for Visit & Services Received
From DTC (N=29)
Unknown (N=92)
Symptoms (N=32)
Had STD Exam
20 (69%)
54 (59%)
32 (100%)
STD Diagnosis
5 (25%)
18 (33%)
23 (72%)
Tested for HCV
29 (100%)
69 (75%)
24 (75%)
HCV+
22 (76%)
43 (62%)
9 (38%)
Hep A Vaccine
9 (31%)
29 (32%)
9 (28%)
Hep B Vaccine
25 (86%)
71 (77%)
26 (81%)
In this slide I try to argue that the “others” are more similar to those who came specifically for hepatitis than to symptomatic clients. Thereby trying to say that perhaps more like 84% idu’s came specifically for hepatitis.
DTC and Other do not complain of symptoms …
Here note the percentages having exams and dx’s are similar between dtc and other
Also note percentage + for HCV
I would argue that Others may also be primarily attending for hep services
ALSO note that hep a vaccine administration is low across all groups compared to hep b vaccine. Since patients accept hep b is seems clear that they are not being offered hep a as much (probably because md’s are not assessing idu risk consistently)

19. Results Unexpected Finding
70 patients tested for HCV and HIV on the same day, with the same counselor
84% (59) documented as IDU on HCV form (by the counselor)
29% (20) documented as IDU on HIV form (by the counselor)

20. Conclusions Recommendation
Integrated hepatitis services brings in new IDU clients to the STD clinic – who may not have otherwise visited the clinic
At least 40% of IDU came specifically for hepatitis services
IDU clients who come to the STD clinic for hepatitis services also utilize and benefit from traditional STD services
Recommendation
Increase outreach and advertising in DTC, SEP and CBO that provide support to IDU populations

21. Conclusions Recommendations
Physicians do not consistently identify IDU risk
Nearly half of IDU were NOT identified by the physician (patient denied history)
Only 31% of IDU received the recommended vaccine for hepatitis A
Recommendations
Might indicate the need to train physicians on eliciting drug history
Why? Remember there is still stigma attached to IDU. Also a physician is seen as an authority figure … someone you want to please. Finally, the physician in this clinic is the first person to see the patient and the first to ask the question. By the time they reach a counselor – they have had time to think about the question. Also, the counselor is probably seen as less official, more like a peer.

22. Conclusions Discussion
HIV/HCV counselors do not record IDU risk on HIV CTS consistently
Only 34% agreement of IDU history in joint counseling sessions
Discussion
Hepatitis C counseling appears to increase the identification of IDU risk among patients obtaining HIV testing
Which in turn may lead to more specific risk reduction counseling
But – the good news is that hep c counseling helps them identify IDU and that may mean (if not great documentation) at least better counseling messages

23. Discussion Possible reasons for discrepancy
HCV form (unlike the HIV form) requires the counselor to answer YES or NO for each risk factor
STD counselors may be more comfortable with talking about sexual exposures around HIV rather than drug use

24. Recommendations Provide counseling staff with more training on IDU
Consider providing safer injection brochure to all patients during HIV and HCV counseling session
Emphasize these findings when training staff in 2 new STD clinics set to provide hepatitis services (expected March 2003)
Continue to monitor and report results to staff
Invite the Harm Reduction Coalition to speak to counseling staff

25. What Have We Done?
Remind counselors that IDU continues to be an important risk for HIV
Emphasize the need for accurate risk assessment on the HIV CTS
Encourage physicians to offer all recommended hepatitis services to IDU patients
Have seen preliminary improvements in risk assessment and HIV CTS forms
Invite the Harm Reduction Coalition to speak to counseling staff

26. Acknowledgements Susan Blank, MD, MPH Assistant Commissioner
Bureau of STD Control
Alan Dunn, MD
Physician in Charge
Riverside STD Clinic
Riverside STD Clinic Staff

27. New York City Department of Health and Mental Hygiene
Contact Information
Robin R. Hennessy
NYC DOHMH
Bureau of STD Control
New York City Department of Health and Mental Hygiene